Provider Demographics
NPI:1629402011
Name:KEALY, AMANDA LEE (LPN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:KEALY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 AVERY RD
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-4415
Mailing Address - Country:US
Mailing Address - Phone:315-404-0483
Mailing Address - Fax:
Practice Address - Street 1:108 AVERY RD
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-4415
Practice Address - Country:US
Practice Address - Phone:315-404-0483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301876164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse